Karpa, Kelly Dowhower RPh, PhD; Vrana, Kent E. PhD
For more than 40 years, medical schools have used problem-based learning (PBL) as an instructional method to nurture students’ problem-solving skills and stimulate self-directed learning.1 A central tenet for employing PBL in undergraduate medical education is that basic science concepts are better understood, remembered, and applied when learned in a clinically relevant format. There is wide variation in PBL implementation across medical schools, but at least 109 U.S. medical schools have used this methodology to some extent, and 37 schools have relied on PBL as their major teaching method.2
It is possible, however, that PBL may not have achieved its full potential as a method of instruction in medical schools because of difficulties communicating basic science concepts to students in clinically oriented, self-directed learning environments.3 PBL program graduates have admitted that they do not know “details” and have rated their knowledge of the basic sciences as weaker than that of their conventionally trained peers.4 They also tend to believe that their medical knowledge is based on an understanding of diseases rather than the underlying basic sciences.5,6 In addition, medical students in PBL-intensive programs may not be learning all of the information that basic science faculty consider to be of central importance, or they may develop misconceptions about medical diagnoses or treatments because they receive limited feedback from faculty.3 In the PBL setting, clinical faculty may be unwilling to discuss cases from a basic science standpoint; conversely, basic science faculty may not be capable facilitators for discussions of clinically based problems.7
Recognizing that students may have difficulty assimilating fundamental basic science concepts in the context of PBL, some of the earliest North American medical schools to adopt PBL have begun to add more lecture-based sessions to their curricula.7,8 Thus, there is growing awareness among medical educators that it is critical to find a way to balance the development of clinically relevant problem-solving skills with the mastery of basic science concepts in undergraduate medical education.
The Challenges of Pharmacology Instruction in a PBL-Based Curriculum
Integrating pharmacology instruction into a PBL-based curriculum poses challenges to educators because pharmacology is both a basic science and a clinical science. Questions commonly arise regarding where and how to teach the discipline in the preclinical years of the medical school curriculum. Some educators believe it should be taught as a basic science in a lecture-based format, whereas others argue that it should be taught in the context of case-based learning, after students have achieved the strong foundation in the basic sciences that is crucial for understanding pharmacology. Those that hold the latter view believe that students more readily acquire essential pharmacology knowledge (mechanisms, adverse effects, etc.) by integrating information about drugs into what they already know about biological and physiological pathways rather than just memorizing facts about drugs as they would in a traditional format.
On the other hand, learning pharmacology in the clinical context of PBL does not provide medical students with a conceptual framework for approaching the discipline. Self-directed learning implies a maturity in relation to the course material; that is, for PBL to be successful, students must have sufficient familiarity with the subject matter to formulate pertinent questions.9 Self-directed learning also implies that learning competence exists; in other words, it depends on the individual’s ability to know when an answer is sufficient for a specific situation and when to keep digging.9 First- and second-year medical students may not have such competence when it comes to pharmacology because their unfamiliarity with the subject prevents them from identifying the gaps in their own knowledge. A constant concern for students approaching pharmacology for the first time in a PBL environment is that they are not sure exactly what drug information they need to learn (e.g., mechanisms, pharmacokinetics, side effects, drug interactions, differentiating individual compounds from others in the same class). It is the information they may inadvertently omit from the self-directed learning process that worries them the most. Their very lack of knowledge and experience with the subject matter may therefore impair the self-assessment process because students cannot know that they do not have sufficient competence without external guidance.9 Students in PBL-intensive curricula may gloss over difficult pharmacology concepts in favor of material that is of more immediate interest. Thus, because of the nature of the process, the PBL mechanism may be poorly suited for pharmacology instruction.
Furthermore, not all pharmacology topics are equally appropriate for PBL.10 For example, it is difficult to gain a comprehensive understanding of antimicrobial drugs in an exclusively PBL environment unless faculty develop a wide variety of cases, including those that cover several rare infections. In addition, the dynamic nature of drug approvals and recalls, new indications, and modified treatment guidelines only complicates the self-directed learning process for pharmacology. Discrepancies between information in textbooks—which often lack state-of-the-art information on drugs—and online resources can be confusing. As a result, students in PBL curricula have consistently expressed a desire to have more organization and structure in the PBL learning environment.5
In this article, we describe how educators at the Pennsylvania State University College of Medicine (Penn State COM) addressed these challenges by creating what we refer to as a “virtual” pharmacology curriculum. In the absence of a stand-alone, lecture-based pharmacology course, we developed a pharmacology curriculum that effectively weaves instruction through the entire medical school curriculum, with particular emphasis on the PBL-intensive second year. This curriculum teaches pharmacology in a spiraling manner intended to continually add to students’ knowledge and competency. It incorporates regular pharmacology review sessions that allow students to gauge their knowledge and understanding of drugs in the context of United States Medical Licensing Examination (USMLE)-type questions and, through study guides we developed, offers students a structured approach for learning about the drugs they encounter in PBL cases.
Creating a Virtual Pharmacology Curriculum at Penn State COM
Concerns about pharmacology instruction
In 1998, Penn State COM moved from a traditional, discipline-based curriculum to a hybrid curriculum. The year 1 curriculum remained primarily lecture based and included instruction for the disciplines of anatomy (Structural Basis of Medical Practice), physiology, biochemistry, and microbiology, which were integrated as Cell and Molecular Basis of Medical Practice and Biological Basis of Disease. Year 2 was transformed into an organ-based curriculum, largely driven by PBL cases and lacking a stand-alone pharmacology course or a framework for pharmacology instruction across cases. Over the next few years, however, medical students, faculty, and outside evaluators (i.e., Liaison Committee on Medical Education) raised concerns about deficits in students’ basic pharmacology knowledge. By the 2002–2003 academic year, pharmacology had been described as the curriculum’s “weakest link.”
The difficulties that Penn State COM experienced with integrating pharmacology into its PBL curriculum are not unique. Authors at other medical schools have described similar struggles and have expressed concern that the discipline is relatively neglected in PBL-based medical training.5,6,11 Moreover, as we noted above, PBL graduates have reported that the breadth and depth of their pharmacology knowledge is lacking when compared with that of their traditionally trained peers.5,6,11
Assessment of pharmacology content in the first two years of the curriculum
Once it became apparent that Penn State COM’s pharmacology curriculum needed attention, a licensed pharmacist and PhD-trained pharmacologist (K.K.) was hired to assess the first two years of the medical school program. This evaluation began in March 2003. The evaluator compared the preclinical curriculum’s pharmacology content with the content of several respected medical pharmacology texts and with the Pharmacology Knowledge Objectives developed by the Association of Medical School Pharmacology Chairs (AMSPC) (http://www.amspc.org/Knowledge_Objectives_2008/index.htm), which were created as a guide for curriculum committees and are particularly relevant for curricula that involve self-directed study/independent learning. (The ongoing revision of the AMSPC Pharmacology Knowledge Objectives is currently incorporating National Board of Medical Examiners guidance and information from the Association of American Medical Colleges’ [AAMC’s] “Report X” on safe prescribing practices.12,13
The curricular analysis exposed areas of duplication as well as gaps in pharmacology content. After the evaluator presented her recommendations to the vice dean for medical education, course directors, and members of the curriculum oversight committee, the medical school created a new master educator position: director of medical pharmacology instruction (50% full-time equivalent [FTE] initially; 75% FTE currently). This pharmacology educator (K.K.) was broadly charged with “fixing” pharmacology in the curriculum. The strategies used to address the curricular inadequacies that the evaluation identified are described below.
Increased lecture-based instruction
First, the pharmacology educator suggested changes, modifications, or additions to lecture content as well as revisions of PBL materials, primarily in the second-year curriculum. Second, she worked with faculty to integrate new pharmacology lectures into nearly every organ-based course throughout the year 2 curriculum; some of these additional lectures were instituted as early as March 2003.
Presently, the first two years of the Penn State COM curriculum continue to immerse students in PBL (students spend 17% of year 1 contact hours and 40% of year 2 contact hours in PBL); however, we have been able to identify critical “touch points” at which formal pharmacology instruction is necessary and have added lecture-based instruction accordingly (Figure 1). Overall, the number of pharmacology-intensive lecture hours nearly doubled from 31 in 1998–1999, when the PBL-based curriculum was introduced, to 61 in 2009–2010, when all year 1 and 2 components of our virtual pharmacology curriculum were in place. The content covered by these lectures has been deliberately added to the preclinical curriculum in a spiraling fashion.14 That is, the pharmacology curriculum is now configured such that when students learn about a drug early in the curriculum, they are given basic information about its mechanism; when they encounter the drug again, they receive expanded and deeper information so that they can place it into a clinical context. The spiraling process occurs for most drugs. This learning-through-reinforcement allows pharmacology content to be approached both as a basic science that is initially focused on mechanisms and as a clinical science in which drugs are subsequently considered from a pharmacotherapeutic perspective.
Table 1 presents the pharmacology lecture content as a function of total lectures for each of Penn State COM’s year 1 and 2 courses for academic years 2002–2003 and 2009–2010. Most courses now place a greater emphasis on pharmacology than in the past. Adding lectures to an already-full curriculum was not always easy, however. Course directors frequently resisted adding new lectures and had to obtain permission from curriculum oversight committees before they could change course content. The support we received from the medical school’s executive administration was essential for the successful modification of the preclinical curriculum. Table 2 compares pharmacology contact hours by setting and by instructional faculty across the medical school’s major curricular transitions.
Introduced pharmacology review sessions
As a means of quickly filling gaps that the evaluator identified in the curriculum, optional pharmacology review sessions were first offered to the second-year medical students in October 2003. These sessions were mini-lectures intended to cover material that was missing from the curriculum. Some sessions were led by pharmacology graduate students who expressed interest in teaching, but we found that they were not able to address the content from the clinical perspective as medical students desired. Further, medical students were not anxious to sit through more lectures.
Currently, 20 to 30 optional, faculty-led pharmacology review sessions are offered to second-year medical students throughout the academic year, but they are no longer structured as lectures to fill gaps. Instead, these sessions supplement the organ-based curriculum and allow students to gauge the depth of their pharmacology understanding on an ongoing basis. The faculty member leading the session (K.K.) reviews the material in the context of USMLE-type questions to highlight pertinent, high-yield aspects of the topic. An audience response system (e.g. “clickers”) is often used so that students can compare their knowledge with that of their peers.
To explore whether these pharmacology review sessions have an impact on USMLE Step 1 performance, we invited 30 second-year students to share their Step 1 score reports with us at the end of the 2010–2011 academic year. (Students were offered five-dollar gift cards for their participation; Milton S. Hershey Medical Center institutional review board exemption #36816.) We identified 15 of these students on the basis of their regular attendance at the pharmacology review sessions; the other 15 students were selected as a nonattendee control group. Ten students (5 from each group) submitted copies of their score reports to the pharmacology administrative office. Although the number of participants was small, we observed a significant difference in overall USMLE Step 1 scores between these two groups: Students who regularly attended the pharmacology review sessions scored higher on the entire exam than did nonattendees (mean scores of 247 versus 230, respectively; P = .038).
There are several possible reasons for these results. First, the review sessions’ discussion format may enhance knowledge acquisition by engaging students in ways that promote active learning and retention. Second, understanding pharmacology mechanisms requires a foundation of physiology, pathology, and biochemistry knowledge; therefore, it is possible that a review of pharmacology material reinforces knowledge of these other basic science disciplines. Third, reviewing USMLE-type questions with a faculty member may help regular attendees develop the thought processes required for success on standardized examinations. Finally, there could be a self-selection bias whereby the students who are inclined to attend the review sessions are stronger academic performers than their peers. However, using mean GPA in years 1 and 2 as a measure, we found there to be no difference in academic aptitude between the regular review session attendees and the nonattendees in our sample (2.87 versus 2.19, respectively, on a four-point scale; P = .12). Although the small sample size limits our ability to draw overall conclusions, these data support continuation of the pharmacology review sessions. We are presently collecting additional data to explore this association further as others have also reported that optional board review sessions are deemed valuable by students and result in higher scores on medical licensing examinations.15
Developed pharmacology study guides for second-year PBL cases
We have also added more structure for pharmacology content to the second-year curriculum. Since August 2009, we have created pharmacology study guides for every second-year PBL case to “level the playing field” because some PBL facilitators place more (or less) emphasis on pharmacologic discussions. Each study guide lists the drugs contained in the case as well as related medications; mechanisms of action, adverse effects, and clinical pearls are included for each drug class. To help students prioritize their study, we indicate which drugs should be learned in detail in the current organ block versus those that will surface again later, which is consistent with the spiraling nature of the pharmacology curriculum. For students who wish to explore the drugs further on a basic science level or to delve deeper into the clinical perspective, we provide suggested readings from an organ-based pharmacology review textbook that we authored and from a clinical pharmacology text, respectively. Because the intent of PBL is self-directed learning, each study guide is posted online after its PBL case concludes to help students identify any important drug information they may have missed while preparing for the case on their own.
After we learned from students that most students were not reading the assigned, encyclopedic pharmacology textbook—they were instead relying on a pharmacology review book—the PBL pharmacology study guides became assigned readings. Students are now told to expect that some examination questions will be derived from the information these guides contain.
Incorporated pharmacology content on course examinations
Medical students also admitted to pharmacology faculty that they did not spend time learning the pharmacology of the drugs that they encountered in PBL cases. Their reasoning was simple: As organ-based course examinations generally included only two questions from each PBL case and most PBL facilitators did not require thorough discussions of drugs, students were “betting” that the tests would not include any pharmacology content. Many students, therefore, only studied the pharmacology material presented in lectures. This practice, of course, resulted in tremendous gaps in students’ pharmacology knowledge—gaps that students often discovered only weeks before taking their USMLE Step 1 exams.
Others have also identified shortcuts that students take that can undermine the goals of the PBL process.10 Students need to be tested on material and held accountable; otherwise, they do not effectively master it.11 Therefore, since August 2009, additional pharmacology content has been added to each organ-based course examination. The pharmacology educator (K.K.) submits two pharmacology questions derived from each PBL case to the relevant course directors to facilitate this additional pharmacology content testing (Table 1), which gives students an incentive to study PBL cases’ pharmacology material on a deeper level.
Developed pharmacology learning objectives for the preclinical curriculum
As we noted above, students find learning pharmacology in a PBL context to be challenging in that they are not sure exactly what they need to learn. Learning objectives should be a central tenet when developing new undergraduate medical curricula.16 With learning objectives, students know precisely what they are expected to learn. Furthermore, when appropriately constructed, behaviorally oriented learning objectives outline a clear series of concepts that enable students to be self-directed learners with a high degree of autonomy.
Our initial efforts, in 2008, were aimed at ensuring that faculty outlined pharmacology-specific learning objectives for each pharmacology lecture. However, when we examined these learning objectives in greater detail, it became apparent that some faculty considered lists of topics covered in a lecture to be synonymous with learning objectives. A concerted effort has therefore been undertaken to ensure that learning objectives are written in a behavioral fashion; that is, each objective clearly indicates what the student is to know and in what context the student will be expected to demonstrate mastery. There has been a marked improvement in this facet of our curriculum (Table 3). Since January 2011, we have been working to incorporate appropriately constructed pharmacology learning objectives into each PBL case as well.
Increased pharmacology educational opportunities in the clinical years
In addition to addressing the gaps in pharmacology education that we identified in the basic science years of the curriculum, we have increased clinical pharmacology educational opportunities for third- and fourth-year medical students. When students enter their clinical rotations, they face a number of pharmacology-related challenges. Chief among these is learning the trade names for the drugs to which clinicians and patients refer; this is akin to learning a foreign language because students learn drugs’ generic names during their first two years of medical school. To assist with this transition, we developed an alphabetized brand-to-generic pocket guide in 2006 (updated biennially) that enables students to discretely and quickly look up a drug by its trade name and associate that trade name with both a generic drug and a mechanism of action. This permits students to participate more effectively in interactions with patients and health care providers.
Our spiraling pharmacology curriculum progresses into the clinical years of medical school by incorporating clinical pharmacology workshops and simulation sessions that cover critical topics. For example, medication reconciliation and medication safety have been incorporated into a patient-centered medical home longitudinal elective for third- and fourth-year medical students that was launched in July 2011 and will be rolled out to the entire class as a required course over the next three years.17,18 This elective addresses most areas of concern raised by the AAMC’s report on safe prescribing practices.12 Moreover, a complementary and alternative medicine elective was launched in March 2008 for fourth-year students who wish to learn evidence-based information about dietary supplements in the context of disease and clinical care.19
Critical Analysis and Ongoing Evaluation
There are challenges to managing a “virtual” pharmacology curriculum that is threaded throughout the educational program but lacks formal recognition as a stand-alone course. Nonetheless, we believe that our current pharmacology program captures the benefits of both lecture- and PBL-based instruction. Using the methods and following the timeline (Table 4) outlined in this article, we have been able to develop a basic science framework for pharmacology via instructor-directed study and review sessions as well as a parallel and integrated PBL thread that allows students to explore pharmacology in clinical cases in ways that are commensurate with their understanding of the basic sciences.
The greatest indicators of the success of our virtual pharmacology curriculum lie in our graduates’ perceptions of their pharmacology training, as indicated on the AAMC Medical School Graduation Questionnaire (GQ), and in their improved pharmacology knowledge, as determined by their performance on standardized tests. Before we began to implement the changes described in this article, just 26% of our 2004 graduates (who took the original second-year PBL curriculum in 2001–2002) rated their pharmacology education as “good” or “excellent” on the GQ.20 This percentage has more than doubled since we began to introduce the curricular changes described in this article. On the 2011 GQ, 61% of our graduates rated their pharmacology education as “good” or “excellent” (P = .02).21 Over the same period, the proportion of our graduates rating their pharmacology preparation as “poor” diminished substantially (60% of 2004 graduates versus 13.9% of 2011 graduates; P < .01).20,21
It should be noted that our 2011 graduates had more pharmacology lectures than previous years’ graduates and were able to attend USMLE-question-based pharmacology review sessions. However, when they were enrolled in the second-year, organ-based courses, we had not yet introduced the pharmacology study guides or added pharmacology questions derived from drugs encountered in PBL cases to course examinations. Therefore, we are optimistic that a positive impact from these later curricular enhancements will be reflected in future graduates’ GQ responses.
In addition, we have seen a positive shift in students’ performance on the pharmacology subsection of the USMLE Step 1. Before the initiation of these curricular innovations, our students’ pharmacology scores were 0.5 standard deviation units below the national mean; during the past three years for which score reports are available (2008–2010), their scores have shifted to within 0.1 standard deviation units of the mean (both above and below; data not shown).22
Our efforts to improve pharmacology medical education are not static; rather, they are ongoing and subject to modification. We are presently collecting data to determine whether there are discernible differences in USMLE Step 1 performance among three distinct groups of second-year students: those who attend pharmacology review sessions, those who download the pharmacology study guides but do not attend the review sessions, and those who neither download the study guides nor attend the review sessions.
Although PBL was originally intended as the basis for a complete preclinical curriculum, it is becoming apparent that it is more appropriate as a teaching method that can be added to a teacher’s tool kit rather than as a sole educational strategy. We believe that our experiences and virtual pharmacology curriculum are relevant to educators at other medical schools who are also struggling with integrating pharmacology into PBL-based curricula. As we have demonstrated, the challenges inherent to the delivery of pharmacology instruction within a PBL-intensive curriculum can be overcome by adding additional structure and oversight into the educational process. Our curricular modifications—appropriately integrated pharmacology lectures, regular pharmacology review sessions, clear learning objectives, study guides for PBL cases, and the addition of more pharmacology questions to course examinations—have improved the pharmacology instruction provided at Penn State COM.
Acknowledgments: The authors wish to thank Susan Boehmer for statistical analysis and Marie Graybill for editorial assistance.
Funding/Support: The authors wish to acknowledge the Association of Faculty and Friends of the Pennsylvania State University College of Medicine and Milton S. Hershey Medical Center for support which allowed them to purchase gift cards.
Other disclosures: None.
Ethical approval: Exemption was obtained from the Milton S. Hershey Medical Center investigational review board (#36816).
Previous presentations: Portions of this work were presented at the Association of Medical School Pharmacology Chairs Meeting, Maui, Hawaii, January 27, 2012, and at the Experimental Biology Meeting, San Diego, California, April 23, 2012.
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